Killing us softly

A recent public outcry in China, sparked by a damning documentary about air pollution, was based on well-founded fear:

Of the 100 million people who viewed the film on the first day of its online release, 172,000 are likely to die each year from air pollution-related diseases, according to regional trends.*

Worldwide, pollution kills twice as many people each year as HIV/AIDS, malaria and tuberculosis combined,** but aid policy has consistently neglected it as a health risk, donors and experts say.

Air pollution alone killed seven million people in 2012, according to World Health Organization (WHO) figures released last year, most of them in low and middle-income countries (LMICs) in the Asia Pacific region.***

In a self-critical report released late last month the World Bank acknowledged that it had treated air pollution as an afterthought, resulting in a dearth of analysis of the problem and spending on solutions.

“We now need to step up our game and adopt a more comprehensive approach to fixing air quality,” the authors wrote in Clean Air and Healthy Lungs. “If left unaddressed, these problems are expected to grow worse over time, as the world continues to urbanise at an unprecedented and challenging speed.”

A second report released last month by several organisations – including the Global Alliance on Health and Pollution, an international consortium of UN organisations, governments, development banks, NGOs and academics – also called for more funding towards reducing pollution.

“Rich countries, multilateral agencies and organisations have forgotten the crippling impacts of pollution and fail to make it a priority in their foreign assistance,” the authors wrote.

Housebound in China

A dense haze obstructs visibility more often than not across China’s northern Hua Bei plain and two of its major river deltas. Less than one percent of the 500 largest cities in China meet WHO’s air quality guidelines. Anger over air pollution is a hot topic among China’s increasingly outspoken citizenry.

“Half of the days in 2014, I had to confine my daughter to my home like a prisoner because the air quality in Beijing was so poor,” China’s well-known journalist Chai Jing said in Under the Dome, the independent documentary she released last month, which investigated the causes of China’s air pollution.

The film was shared on the Chinese social media portal Weibo more than 580,000 times before officials ordered websites to delete it.

Beyond the silo

Traditionally left to environmental experts to tackle, the fight against pollution is increasingly recognised as requiring attention from health and development specialists too.

“Air pollution is the top environmental health risk and among the top modifiable health risks in the world,” said Professor Michael Brauer, a public health expert at the University of British Columbia in Canada and a member of the scientific advisory panel for the Climate and Clean Air Coalition, a consortium of governments and the UN Environment Programme. “Air pollution has been under-funded and its health impacts under-appreciated.”

Pollution – especially outdoor or “ambient” air pollution – is also a major drag on economic performance and limits the opportunities of the poor, according to Ilmi Granoff, an environmental policy expert at the Overseas Development Institute, a London-based think tank. It causes premature death, illness, lost earnings and medical costs – all of which take their toll on both individual and national productivity.

“Donors need to get out of the siloed thinking of pollution as an environmental problem distinct from economic development and poverty reduction,” Granoff said.

Pollution cleanup is indeed underfunded, he added, but pollution prevention is even more poorly prioritised: “It’s underfunded in much of the developed world, in aid, and in developing country priorities, so this isn’t just an aid problem.”

Mounting evidence

Pollution kills in a variety of ways, according to relatively recent studies; air pollution is by far the most lethal form compared to soil and water pollution.

Microscopic particulate matter (PM) suspended in polluted air is the chief culprit in these deaths: the smaller the particles’ size, the deeper they are able to penetrate into the lungs. Particles of less than 2.5 micrometres in diameter (PM2.5) are small enough to reach the alveoli, the deepest part of the lungs, and to enter the blood stream.

From there, PM2.5 causes inflammation and changes in heart rate, blood pressure, and blood clotting processes - the precursors to fatal stroke and heart disease. PM2.5 irritates and corrodes the alveoli, which impairs lung function - a major precursor to chronic obstructive pulmonary disease. It also acts as a carcinogen.

Most research looks at long-term exposure to PM2.5 but even studies looking at the hours immediately following bursts of especially high ambient PM2.5 (in developed countries) show a corresponding spike in life-threatening heart attacks, heart arrhythmias and stroke.

Asia worst affected

The overwhelming majority - 70 percent - of global air pollution deaths occur in the Western Pacific and Southeast Asia regions. South Asia has eight of the top 10 and 33 of the top 50 cities with the worst PM concentrations in the world.

WHO says a city’s average annual PM levels should be 20 micrograms per cubic meter. But cities such as Karachi, Gaborone, and Delhi have yearly PM averages above 200 micrograms per cubic meter.

The main source of PM2.5 in indoor air, or household air, is burning solid fuels for cooking and heating, using wood, coal, dung or crop leftovers - a common practice in rural areas of low and middle-income countries that lack electricity.

Almost three billion people live this way, the majority in the densely populated Asia Pacific region: India and China each hold about one quarter of all people who rely on solid fuels. For these people, the daily average dose of PM2.5 is often in the hundreds of micrograms per cubic meter.

Filling the gaps

Unlike many other health risks air pollution is very cost-effective to address, Brauer said. Analysis of air quality interventions in the US suggests a return on investment of up to $30 for every dollar spent.

“We already know how to reduce these risks, as we have done exactly that in high income countries, so this is not a matter of searching for a cure - we know what works,” he said.

But the World Bank report said that unless it starts gathering better data on local air quality in LMICs, the amounts and sources of air pollution and the full gamut of its health impacts, “it is not possible to appropriately target interventions in a cost-effective manner.”

Granoff said there are also gaps in government capacity to monitor, regulate and enforce pollution policy.

Beijing hopes to bring PM2.5 concentrations down to safe levels by 2030, and has said it will fine big polluters.

The World Bank report said China is also charging all enterprises fees for the pollutants they discharge; establishing a nationwide PM2.5 monitoring network; instituting pollution control measures on motor vehicles; and controlling urban dust pollution.

But enforcing environmental protections has been a longstanding problem in China.

“Pollution policy will only succeed if citizens are aware of the harm, able to organise their concern [through advocacy campaigns], and have a responsive government that prioritises public welfare over the narrower interests of polluting sectors,” Granoff said.

While more people die from household air pollution than from ambient air pollution, the latter – through vehicles, smokestacks and open burning – still accounted for 3.7 million deaths in 2012, according to the WHO.

A change in the air

Kaye Patdu, an air quality expert at Clean Air Asia, a Manila-based think tank - and the secretariat for the UN-backed Clean Air Asia Partnership, comprising more than 250 government, civil, academic, business and development organisations - said the aid community is finally starting to recognise the importance of tackling air pollution.

•Last year’s inaugural UN Environment Assembly adopted a resolution calling for strengthened action on air pollution.
•WHO Member States are planning to adopt a resolution on health and air quality at the upcoming World Health Assembly in May.
•The proposed Sustainable Development Goals, which will set the post-2015 international development agenda, address city air quality and air, soil and water pollution.

None of the experts IRIN contacted could provide a breakdown of total aid spending on all forms of toxic pollution (air, water and soil pollution that is harmful to human health). So IRIN asked each of the major global donors for their figures.

Three responded.

A back-of-envelope calculation of all reported spending on toxic pollution by USAID, the European Commission and the World Bank suggests that between them they committed about US$10 billion over 10 years. This does not include aid spending on the diseases that pollution causes. The World Bank’s spending figures eclipsed those of other the other donors.

By very rough comparison, HIV/AIDS, malaria and tuberculosis, with half the death toll of air pollution, received $28 billion via public sector commitments to the Global Fund – the world’s largest financier of programs that tackle these diseases – over the same period, a fraction of total spending on these diseases.

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*Based on WHO statistics for per capita mortality rates in the Western Pacific region in 2012.

**The mortality figures for air pollution come from 2012 statistics and were released by WHO in 2014, while the figures for the infectious diseases come from 2013 statistics and were released by the Institute for Health Metrics and Evaluation in 2014 (the Global Burden of Disease study).

***Includes deaths from both household air pollution (4.3 million) and ambient air pollution (3.7 million): the combined death toll is less than the sum of the parts because many people are exposed to both.